Primary care physicians consider the totality of your physical and mental health, instead of focusing on organ-specific medicine. Generalists also emphasize prevention of illness rather than on specialized emergent care for patients who are acutely sick. It is wonderful to have an ongoing personal relationship with someone who cares about the wellness of you and your family.
For all of these reasons, primary care is the principal locus of the treatment of most chronic illnesses in the community -- with the notable exception of the acute phases of the treatment of cancer. The most common disabling and life-threatening common illnesses -- arthritis, heart failure, hypertension, diabetes and depression -- are all managed in primary care. Specialists care for a tiny fraction of patients with these important public health problems.
The opportunities to make a difference in primary care are endless. Whether you consider yourself a family physician (whose practice includes pediatrics and women's health) or a general internist (who focuses on physical ailments of adults), the range of health problems requiring your expertise is vast. Your ability to focus on patient care rather than procedures should be liberating.
But, these ideal conditions often do not prevail in the read world. Assuming there are no new patients, the daily schedule of the average primary care physician allows for incredibly short patient visits, each lasting 15-17 minutes. The visit duration is less than 10 minutes in urban solo practices. The is 2-5 minutes.
During that time, the practitioner typically sits at a computer screen, which depicts the medical history, including medications that the computer thinks the patient is taking (whether or not they actually are). For each illness, there is a required checklist of items that must be accomplished at each visit (or at periodic intervals). If the checklist is not completed as specified, the physician is not paid.
Consider a patient who has heart failure. (I pick this disease because it is my area of expertise.) To understand how a patient with heart failure is doing, physicians need to assess symptoms and limitations. (Many heart failure specialists ask patients to walk with them around a hallway.) They need to check for signs of fluid retention to adjust the dose of diuretics. They need to make sure that patients are receiving at least four other drugs that are known to prolong life, and to titrate the doses of these drugs so that patients are being adequately protected. And they should check whether there are any physiological abnormalities that might require a device or procedure. Overall, physicians need to orchestrate among at least seven treatments, which are used typically in combination. Each one has specific indications and contraindications.
Most heart failure specialists have committed all of this to memory, but even when such knowledge is at their fingertips, it is nearly impossible to achieve these goals in 5-15 minutes.
Yet, most patients with heart failure are cared for in primary care. Family physicians do not have all of the information about the current management of heart failure in their heads. And there is no time to read the literature or look up guidelines. There is certainly no time to start a new medication (which requires some discussion and explanation). And if the new treatment needs any paperwork, there is little chance that it will be part of the discussion.
If a patient has chronic heart failure, what can you do in 10-15 minutes? You can determine what is required for you to be paid, and you can check boxes.
The typical discourse with a patient with heart failure: How is your breathing? About the same? Well, you have heart failure; what do you expect? But it isn't getting worse, right? OK. Well, continue taking your medications. (All too often, this means a low dose of a diuretic and an ACE inhibitor, which is how heart failure was treated in 1989.)
Of course, this assumes that the patient has only one disease -- heart failure.
Most patients with heart failure have many other chronic disorders, like diabetes, arthritis, depression and hypertension. Each has its own checklist.
What if the patient has a new complaint? Heaven forbid; there is simply no time to listen or figure it out.
Suppose the patient says: I am feeling a bit depressed. A physician's response might be: OK, I am going to prescribe an antidepressant. Why? It takes much less time to prescribe a psychotropic drug than to make the proper diagnosis of depression.
What if the patient has diabetes? There has been amazing progress in forestalling the development of serious heart and kidney disease in patients with diabetes. This progress involves three classes of drugs that do not act primarily by lowering blood glucose. But the physician is paid only for checking and lowering the blood glucose. And to do so, they typically prescribe the same drugs that were used for diabetes 25 years ago (insulin, sulfonylureas and perhaps, metformin). These drugs are not known to prevent heart attacks or heart failure, and their aggressive use has been reported to increase the risk of death. But they are familiar. (Typically, they are also inexpensive, although the recently).
The end result: in primary care, most patients with heart failure who are not receiving drugs that can save their lives, and most patients with diabetes are not being treated with the best medications to prevent major heart or kidney disease. For most, the management of their chronic illness has not changed in 20-30 years. But they are being prescribed a lot of antidepressants.
Specialists in cardiology and nephrology know about this problem, but most are at a loss of what they can do. What do they do? They write guidelines! Typically, the documents are 200 pages long.
The writing of disease-focused guidelines does not make things better. No one in primary care has the time to read any of the text for any one disease, let alone all of them. No one can keep up with the ongoing changes; and no one has the time to implement the recommendations.
Primary care physicians know this. How do they respond? The American Academy of Family Physicians typically rejects the vast majority of guidelines issued by specialty organizations. Why? They claim that specialty guidelines are written by individuals with financial conflicts of interest. Regardless of the merits of this claim, it is not the real reason for their rejection. The truth: specialists are in 10-15 minutes.
How do subspecialty organizations respond to this rejection? Sadly, they often double down on their efforts to make life difficult for primary care physicians. Two years ago, two U.S. cardiology organizations lowered their threshold for the identification and adequate management of hypertension. The result: a massive increase in the workload on primary care. The response of primary care organizations? We reject your recommendations.
Without doubt, U.S. patients with many chronic illnesses are not receiving good quality medical care to reduce suffering and prolong life.
What happens if a physician tries to make a difference and spends a bit of extra time? Their schedule runs late. When a survey subsequently asks if their appointment started on time, patients say no. And thus, the physician's patient satisfaction scores suffer.
To get real medical attention these days, you need to have an illness that requires or is amenable to a procedure for which the physician is paid. The result: , we have the most expensive healthcare in the world, but we have worse outcomes.
So if you have diabetes or heart failure, I wish you luck. Your medical care in 2019 probably resembles what good care looked like in 1989-1999. For too many people, advances in treatment over the past 30 years have meant very little.
Let me be clear. I am not blaming anyone. I am certainly not criticizing primary care physicians, who are totally overwhelmed by the current state of affairs. Also, finding someone to blame does not fix the problem.
Our healthcare delivery system for chronic illness is horribly ill, even for those with full access to healthcare. Financialization has hollowed out its core mission and has made it meaningless. Increasing access to a failing medical infrastructure may sound good, but it does not address our core issues.
Healthcare for patients with chronic illnesses in the U.S. is on life support. The medical community seems helpless to fix this problem -- presumably because the solution is political, not medical.
The most important crisis facing U.S. medicine is not access to healthcare. It is access to 21st century healthcare.
Disclosures
Packer recently consulted for Actavis, Akcea, Amgen, AstraZeneca, Boehringer Ingelheim, Cardiorentis, Daiichi Sankyo, Gilead, J&J, Novo Nordisk, Pfizer, Sanofi, Synthetic Biologics, and Takeda. He chairs the EMPEROR Executive Committee for trials of empagliflozin for the treatment of heart failure. He was previously the co-PI of the PARADIGM-HF trial and serves on the Steering Committee of the PARAGON-HF trial, but has no financial relationship with Novartis.